Medical Auditing Practice Exam

When an auditor finds claims for services labeled as Incident-to, but the physician was on vacation, what is this considered?

1. An error that needs correction

2. Fraud

3. A misunderstanding of billing codes

4. Non-compliance

The correct answer is: Fraud

When claims for services labeled as Incident-to are submitted while the supervising physician was on vacation, this situation is regarded as fraud. Incident-to services are those rendered by non-physician practitioners under the direct supervision of a physician. The requirement for direct supervision implies that the physician must be available to provide guidance and oversight during the delivery of those services. If the physician is on vacation and not available at the time the services were billed as Incident-to, this constitutes a misrepresentation of the circumstances surrounding the provision of care. By submitting these claims inaccurately, it suggests an intent to deceive the payer into believing that the services were rendered under appropriate supervisory conditions. This misrepresentation violates regulations designed to ensure that billing accurately reflects the services provided, therefore crossing into fraudulent territory. It is crucial for auditors to identify such discrepancies to maintain the integrity of billing practices and protect healthcare organizations from potential legal ramifications.